accident_report_form - Brooklyn Scouts, Wellington
accident_report_form - Brooklyn Scouts, Wellington
accident_report_form - Brooklyn Scouts, Wellington
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ACCIDENT REPORT FORM<br />
DETAILS OF ACCIDENT<br />
Region:<br />
Zone:<br />
Scout Group:<br />
Section:<br />
Type of Activity:<br />
Activity Location:<br />
(Grid Reference)<br />
Activity Leader<br />
Skills/Experience:<br />
Weather at the time of<br />
Accident:<br />
Fine....... ... Wet<br />
Communication<br />
method used to<br />
raise help:<br />
Mountain Radio<br />
Avalanche Tr.<br />
Hot ....... ... Cold<br />
VHF Radio<br />
Locator Beacon<br />
Calm ..... ... Windy<br />
Satellite Phone<br />
Messenger<br />
High Vis. ... Low Vis.<br />
None used<br />
Other<br />
Number of people on<br />
activity:<br />
Leaders Participants Others<br />
Type of Accident:<br />
Fatality<br />
Equipment loss<br />
Injury<br />
Equipment damage<br />
Date of Accident:<br />
Illness<br />
Missing/Lost<br />
Time of Accident:<br />
Psychological<br />
Other<br />
SEVERITY RATING (select one grade of severity).<br />
Major Accident<br />
(<strong>report</strong> submitted to both National Office and Group)<br />
10. Extreme ........ (multiple fatalities)<br />
9. Grave ............. (single death)<br />
8. Severe ............ (major injury/long term hospitalisation)<br />
7. Major.............. (major injury/hospitalisation > 12 hours)<br />
6. High ............... (major injury/hospitalisation < 12 hours)<br />
Minor Accident<br />
(<strong>report</strong> submitted to Group only)<br />
5. Medium ........... (medium injury/sprain or minor fracture)<br />
4. Modest ............ (Lacerations/mild concussion)<br />
3. Low................. (Blisters/minor dislocation)<br />
2. Minor .............. (Severe sunburn/minor cuts)<br />
1. Minute............. (Splinters/insect bite)<br />
DETAILS OF PERSON INVOLVED (use extra sheets if more than one person).<br />
First Name:<br />
Last Name:<br />
Age:<br />
Ethnicity:<br />
Gender:<br />
Evacuation method:<br />
TYPE OF INJURY SUSTAINED (you may select more than one).<br />
Abdominal problem<br />
Chest pain<br />
Fracture<br />
Near-drowning/drowning<br />
Abrasion<br />
Concussion<br />
Frostbite<br />
Puncture<br />
Allergy<br />
Contusion<br />
Heat stroke<br />
Psychological problem<br />
Altitude sickness<br />
Eye Injury<br />
Hyperthermia<br />
Respiratory problem<br />
Asthma<br />
Eye Infection<br />
Hypothermia<br />
Sprain<br />
Blister<br />
Dislocation<br />
Infection<br />
Strain<br />
Bruise<br />
Fatigue<br />
Laceration<br />
Other (state)<br />
Burn<br />
Food poisoning<br />
Muscle strain/tear<br />
May 2010 <strong>accident</strong>_<strong>report</strong>_<strong>form</strong>.doc
ACCIDENT REPORT FORM<br />
CAUSAL FACTORS INVOLVED (you may select more than one).<br />
Activity Leader<br />
People<br />
Participant<br />
Equipment<br />
Environment<br />
Inadequate physical condition<br />
Inadequate physical condition<br />
No equipment<br />
Adverse weather<br />
Inadequate mental condition<br />
Inadequate mental condition<br />
Wrong equipment<br />
Poor visibility<br />
Inadequate emotional condition<br />
Inadequate emotional condition<br />
Faulty equipment<br />
Terrain<br />
Pre-existing condition<br />
Pre-existing condition<br />
Inadequate equipment<br />
Water (rain/rivers etc)<br />
Judgment/Leadership error<br />
Judgment/Leadership error<br />
Other<br />
Animal/Insect/Plant<br />
Inadequate supervision<br />
Inadequate supervision<br />
N/A<br />
Other<br />
Inadequate skills/experience<br />
Inadequate skills/experience<br />
N/A<br />
Failure to follow guidelines<br />
Failure to follow instructions<br />
Lack of motivation<br />
Lack of motivation<br />
Other<br />
Other<br />
Explanation:<br />
TYPE OF ACTIVITY (you may select more than one).<br />
Abseiling<br />
Fishing<br />
Pioneering<br />
Solo trip<br />
Archery<br />
Flying fox<br />
Rafting<br />
Surfing<br />
Bungy jumping<br />
Horse riding<br />
River crossing<br />
Swimming<br />
Bush craft<br />
Hunting<br />
Rock climbing<br />
Tramping<br />
Camping<br />
Initiative activities<br />
Ropes course<br />
Transportation<br />
Canoeing<br />
Kayaking<br />
Sailing<br />
Tubing<br />
Caving<br />
Land yachting<br />
Scuba diving/Snorkelling<br />
Weekly activity<br />
Commando course<br />
Mountain biking<br />
Sea kayaking<br />
Windsurfing<br />
Cooking<br />
Mountaineering<br />
Skiing<br />
Waterskiing<br />
Cycling<br />
Multisport/Adventure Racing<br />
Snow boarding<br />
Other<br />
Field trip<br />
Orienteering/Rogaining<br />
Snow caving<br />
Narrative:<br />
May 2010 <strong>accident</strong>_<strong>report</strong>_<strong>form</strong>.doc
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